Failure to Follow Resident Transfer Protocols Resulting in Fall
Penalty
Summary
The facility failed to ensure that staff followed the resident's individualized plan of care for safe transfers, resulting in an accident. A resident with a history of stroke, emphysema, COPD, and asthma, who was dependent on staff for all transfers, was care planned to be transferred with the assistance of two staff members using a gait belt and pivot technique. However, the resident's Kardex indicated a transfer with one staff member using a gait belt and walker. On the day of the incident, a CNA attempted to transfer the resident using a sit-to-stand mechanical lift without the required assistance of a second staff member and without properly securing the resident in the lift. During the transfer, the resident slipped out of the sling and fell to the floor, sustaining a lump to the back of the head. Interviews with facility staff confirmed that the CNA acted alone and did not follow the care plan or Kardex instructions. The DON stated that the CNA had not previously used the lift for this resident and could not determine why the CNA chose this method. The LPN who responded to the incident found the resident on the floor and confirmed that the resident was not strapped into the lift at the time of the fall. The resident was sent to the hospital for evaluation and returned with no internal injuries, as confirmed by MRI.